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HomeMy WebLinkAbout020-1128-30-000 (2)Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Building Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)l. ermit Holder's Name: City Village X Township Fletcher, Steven Hudson Townshi ST BM Elev: Insp. BM Elev: BM Description: ,} 1 fl~ c ~~Y/1 ~ [(~( 'ANK IN~f1RMATIAN ELEVATION DATA TYPE MANUFACTURER CAPACITY eptic klicsrr /--fo ~ Dosing Aeration Holding TANK SETBACK INFORMATION PUMP/SIPHON INFORMATION Number Loss rorcemain (Length (Dia. (Dist. to well ~nll nQCnooTlnxl CVCTCM ~ ,r. ~ h_ _ TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic ~' ,3C~ `~~ ~~D f t!~ Dosing Aeration Holding County: $t. CrOIX Sanitary Permit No: 399551 State Plan ID No: Parcel Tax No: 020-1174-60-000 STATION BS HI FS ELEV. Benchmark 3 y~ 10~~ ~ o ~ Alt. BM Bldg. Sewer Z ~~ • Z 6 SUHt Inlet 7, I /o ~ S,~ St/Ht Outlet 7 S Q Dt Inlet Dt Bottom Header/Man. Dist. Pipe Bot. System Final Grade St Cover BEDITRENCH DIMENSIONS Width Length v. v No... f renches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth SETBACK INFORMATION SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING CHAMBER OR Manufacturer. Type Of System: UNIT Model Number: r11CT171R1ITI(1N CVCTFM Header/Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipe(s) Length Dia Length Dia Spacing Cnll Rf1VFR ., o-..~~..-.. c..~ae...~ n.,~.. .... Mnunli nr Af.Arada Svetemw Only Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil ^ Yes ^ No ^ Yes ^ No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: I / / ' 3 /~_ Inspection #2: / / Location: 921 Ridge Pass Hudson, WI 54016 (SW 1/4 SW 1/417 T29N R19W) Willow Ridge 2nd Ad Parcel No: 17.29.19.1097 1.) Alt BM Description = I Z.) Bldg sewer length = - (o ~~ ~~ ~ ~ ~ ~u be ~ -~i ~'te (~- - amount of cover = ~ ~ ~~ _ _ p ~ ~ ~ ri ~ - ' Plan revision Required? ^ Yes ^ No / / r ~ ~ ~ !~- Use other side for additional information. ~ \ Date Insepctor's S tune SBD-6710 (R.3/97) y s ~___J f !kl t~,~I I ~~~ " Safety do Buildings Division ~ Sanitary Permit Application t 1 W. Washington Ave. ` c/SCQ~],i3i~] In accord with Comm 83.21, Wis. Adm. Code Po Box 7302 Madison, Wl 53707-7302 ospertment of commerce Personal information you provide maybe used for secondary purposes (Submit completed form to county if not [Privacy Law, s. 15.04(1) t )-r-~--~~ state owned. Attach com late tans to the count co on) for the t ei' o I hen 8 -1/2 x 11 inches in size. County _ ~ ~ State snits Permit Num ~ ~ O Che i e 'ton tp previous ~pp,~N~at n ' r ' It State Plan .Number J~ p I. A lication Information -Please Print all Information S.1' Location: Properly Owner Name i ~ ~ Property Location ~~ ____ _ ~ Property Owner's M fling Address ''. S 1/4 I/4, S T ,N or W Lot Number Block Number ~ City, Stale ' Zip Code P n er Subdivision Name or CSM Number ~ ~ II ype of Building: (check one) ~ ^ city 1 or 2 Family DweNing - No. of Bedrooms: ^ village _ O PublidCottunercial(describe use): ~~~c"^t of _ O Slate-owned _..------- - -------- - --- -- 1 ~ ' ~ 7 r ~~41 III Type of °~rmlt: (Check only one box on line A. Ch box on line B if applicable) ar goad ~ ~ c(~c .~~ Z`~ )%~ A) 1. ' ,New System 2. ^ Replacement 3. ~Replacernent o 4. O Addition to Parcel Talc Number ) ` S stem T'an Onl Existing System d~U- 7~- ~pUU B) O A Sanity Permit was reviousl issued _ __ Pernr u t c ~7 ` $- t~ " d~D l0 Date Issued IV. Type of POWT System: (Check all that apply) O Non-pressurized In•ground \~is'E1~ ^ Mound ^ Sand Filter ^ Constructed Wetland O Pressurized In-ground ~ 3 1 $' ~ 6 ~ O I lolding 'i'artk O Single Pass O Drip line ~ O At-grade ~~~~ tc// ~ O Aerobic'I'reatment Unit O Recirculating ^ Other: V Dis ersaVl'reatment Area Information: I. Design Flow (gpd) _ 2. DispersalArea 3. Dispersal Area 4. Soil Application 5. Percolation Rate 6. Syst m Elevation 7. Final Grade . `7Sb Required Proposed Rale (Gals./day/sq. 17.) (Min./inch) t' Elevation ------__.-- ---_-~-_ _ _____ _. VI Tank Capacity in Total N of , Manufac~trgr, Prefab Sire Information Gallons Gallons Tanks U S>-~ ~X~ ~' ~ ^- ~ - New Existing - ~ ~ , ~/ 7'attks Tanks j - -Q ~ ~ ~- I ~ S ~ ~\M-- 1 - vim- (/~~ 1 v u xesponatuutty statement for installation a Plumber's Address (Sheet, City, State, I16~ Viii County/Depairtment Use Only u ulsapproved Sanitary Pet Approved O Owner Given Initial Adverse Surcharge F. ~~\\ ~' ~~ Y~~(/ ~~~ ~ ~ ~ 1i"v ~ ~ <~-. \~d "''" ~ ~(~w~ ~ ~Z d IZi:. diNons of Approlval /Reasons for Disapproval; ~'' j ~//ktl' + ~ ~ l"-~`kG~ '~'~ .Gk _ _ _ . ~~T~?~ ~ ~C b C cC~c..Ce . ~ :. , +~ ov~e r,....~{ . ~-tiNC.e, tSUPr~- G-E'S ~'l1 ~.RY.ev~ (©~t~rUYi . r' G~, !fie ~1~c (~ i,~,u.~ 4-e .,~~u~rG~l-~'t' ~~ r7~•os~t ~,~:~e~r" v • ~~c. ~~ .- ~ :. _ I-~ ~ ~ l ffl v .~ / ~/ ~ an~C ~ ~~ cl e cvi nc~e rs _ _ y ~ __. ______.__ _-- -~"~1 um_ab~ ._--..--- _._. ~_. ___. V 5' eVeN T 12 I ~-- S ___ __ ______ 16~~)7 0~ d~i~ G cM:~P N~us-~ ss' _ P2~Po~~ r10VP ~ ~bN~ ~ ~ 8~ ~~ - - - ~- ~b~~r Ql~d iw Y C ^^`` .~ •O W r=+ r~ ~~ ~ Y .` •~ ~ 7 U ~ C C ~ - C ~'~ C U ~ ~ ~ ~ NE~°~ ~T~ ~~ ,"' N ~ 0 0 W I~ X td ~ L X U ~~'v./~ ^` l' J W C n M L(') ~ ~ .D ~ ('7 ~ T /' ~P Private Onsite Wastewater Treatment System Management Plan Septic Tank And Gravity In-Ground Soil Absorption Component Pursuant to Comm 83.54 Wis. Adm. Code each Private Onsite Wastewater Treatment System (POWYS) shall include information and procedures for maintaining the system within the parameters of Comm 83 and 84, and the conditions of approval by the department, agent, or governmental unit. The approved plans and permits for system are on file at the county zoning or health department. This management plan complies with Comm 83.54, Wis. Adm. Code, and the In-Ground Soil Absorption Component Manual for Private Onsite Wastewater Treatment Systems SBD- Table 1: System Design Specifications Sanitary Permit Number Number of Bedrooms 5 Design Flow -Peak (gpd) "? 0 Estimated Flow -Average (gpd) S 0 Septic Tank Capacity (gal) _ 5 5 Soil Absorption Component Size (ft2) ?J Type of Wastewater Domestic Table 2: Soil Absorption Component -Limits of Reliable Operation Septic Tank Component Soil Absorption Component Design Flow -Peak (gpd) f S4 Maximum Influent Particle Size (in) t ~ 1/8 Maximum GODS (mg/L) a lJ 220 Maximum TSS (mg/L) / U 150 Tab le 3: Maintenance Schedule Septic Tank Inspect and/or service once every 3 years Outlet Filter Inspect once a year and clean at least once every 3 years Soil Absorption Component Inspect once every 3 years Septic Tank The septic tank shall be maintained by an individual certified to service septic tanks under s. 281.48, Stats. The contents of the septic tank shall be disposed of in accordance with NR 113, Wis. Adm. Code (Servicing Septic or Holding Tanks, Pumping Chambers, Grease Interceptors, Seepage Beds, Seepage Pits, Seepage Trenches, Privies, or Portable Restrooms). The operating condition of the septic tank and outlet filter shall be assessed at least once every 3 years by inspection. The outlet filter shall be cleaned as necessary to ensure proper operation. The filter cartridge should not be removed unless provisions are made to retain solids in the tank that may slough off the filter when removed from its enclosure. If the '~ Management Plan for a Septic Tank and Soil Absorption Component filter is equipped with an alarm, the filter shall be serviced if the alarm is activated continuously. Intermittent filter alarms may indicate surge flows or an impending continuous alarm. The septic tank shall have its contents removed when the volume of scum and sludge in the tank exceeds 1/3 the liquid volume of the tank. If the contents of the tank are not removed at the time of an assessment, maintenance personnel shall advise the owner of when the next service needs to be performed to maintain less than maximum scum and sludge accumulation in the tank. Manhole risers, access risers and covers should be inspected for water tightness and soundness. Access openings used for service and assessment shall be sealed watertight upon the completion of service. Any opening deemed unsound, defective, or subject to failure must be replaced. Exposed access openings greater than 8-inches in diameter shall be secured by an effective locking device to prevent accidental or unauthorized entry into the tank. No one should enter a sepfic or other treatment or holding tank for any reason without being in full compliance with OSHA standards for entering a confined space. The atmosphere within the septic or other treatment of holding tank may contain lethal gases, and rescue of a person from the interior of the tank maybe difficulf or impossible. Tank abandonment shall be in accordance with Comm 83.33, Wis. Adm. Code when the tank is no longer used as a POWTS component. Soil Absorption Component The soil absorption component serving this structure is designed to accept domestic wastewater from a residential facility. The limits of operation of this component are shown in Table 2. The longevity of a soil absorption component depends greatly on proper and timely maintenance, and system use within or below the limits of reliable operation. Good water conservation practices by all occupants and the installation of water conserving plumbing fixtures are. key factors in extending the useful life of this component. The soil absorption component's operation must be assessed by inspection at least once every three years. The inspection shall include recording the levels of ponding, if any, in the observation pipes, and a visual inspection for any evidence of surface seepage or discharge from the component. On steeply sloping sites, areas of erosion should be identified and reported to the owner for repair. The surface discharge of domestic wastewater or sewage from the system is prohibited and considered a human health hazard. Traffic around or over the soil absorption component should be avoided particularly during winter months. The compaction or removal of snow cover over the component may lead to hydraulic failure by freezing. This type of failure is usually temporary, but is difficult or impossible to repair until weather conditions improve. In general, soil compaction over this component will reduce diffusion of oxygen into the soil and dispersal cell, which may lead to more intense, and earlier, organic clogging of the soil. 2 -~ Management Plan fora Septic Tank and Soil Absorption Component Plantings of deep-rooted trees and shrubs directly over or within ten feet of the component should be avoided since root intrusion into the component may obstruct wastewater flow. When system fails, we will replace with another system at owner's expense. Alternate area must be left undisturbed. St Croix County Zoning Office 386-4680 Boumeester & Sons Excavating 386-9020 Tri-County Sanitation 386-2130 3 S'I' CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer ~,,; .Mailing Address Property Address •M (Verification required Planning Department for new construction) City/State 1-Fla ~_~ ~~1~_~~~ "L parcel Identification Number Property 1~ocation %,, %,, Sec. ~, 'I'N-IZ~W, 'Gown of ~'(~ Subdivision Lot # ~. Cetrtitled Sutrvey Map # Volume ,Page # Warranty Deed # Volume ,Page # Sptc house O yes ~1 no Lot lines identifiable (~ yes O no ~- ~P"OP°r use and matntenanceof your septic system could result in its premature failure to handle wastes. Proper mainteoas-oe coosisb of punsping out the aepijo tank every three years or sooner, if needed by s licensed pumper. What you put into the system can affect the Hrnction of the septic tank as a treatment stage in We waste disposal ayatem. , 1]te iY owner agrees to submit to St. Croix Zoning Depuiment a certification form, signed by the owner and by a nrasterplumber, jotrcneyrnanplumber, restrietedplumber or a liceosedpumper verifying that (1) the on-site wastewaterdispoatl ayaleaa ~ ~ Prope+' opaath~g condiNoa and/or (Zj` s ln~ection and pumping (if necessary), the septic tank is lea flan U3sArU of ah~e. 4. Uwe, the undersigned have red the abov '~ `~` ,'~''~%#'s ~ fem. ~j4 as set the D ..i°°i agree to maintain the private sewage disposal ~taad.cda ~' °M~t and the Department of Natural Resources, State of Wlaooaalo. Oe:tiBcatiaa ~~ fbst Y~ aP~ ~~ has been maintat~ned moat be completed wd returned to the St. Croix Coup days of the three year eapintion date. `~;~ ` °''` • tY Zonins OtBce within 30 • ,• SIt7NATURB O APPLICANT DATE {. , ~,kr> 1 ~ ~ I (we) eettif~- that. all statements oaitlt~; ~ ace true to We best of my (our) knowledge. 1 (we) am (are) the owner(s) v[ the PAY deacrlbed above, y virtue of a:wartaaty deed recorded in Register of Deeds Otrce. • ): ,L'' .~,.. ~b / 09/4 1 SIONAT[JRB OF PLiCANT .:~~,~~ • DATE ~i;•~,'. *~'a'*~ Any information that is mia-cep ~ teauit in the aaaiU tmit bein revoked b the Zvn' ,~~ rY Pe B y •••••• •• ~Y'• utg Department. inciad~ with tbta appUcation: a eta ~ ntped, decd from the Register of Deeds office a copy of dte eerlHied survey map if reference is msde in the warranty deed BUUMEESTER & SOHS EXCAVATING 1070 Highway 35N HUDSON, WISCONSIN 54016 (71.5) 386-9020 . (715) 366-5037 November 5, 2001 .. St. Croix County Zoning Office 1101 Carmichael Road Hudson [~I 54016 Zoning department, The septic system at the Steven Fletcher residence i.s functioning alright. There is not water seeping out of the ground. The septic tank is being moved so that a porch may be constructed. Thank you, ~v~ . .. Jim Boumeester ~• i ' ~ STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER ~~ye~ `-/~e ~C ~'' ADDRESS l~.2/ ,~~r ~;~SS ~G,c GJ,~s :~ ~lv ~'~ (o SUBDIVISION / CSM~ <':.-I~l~o~..> ~rofc~~r~s~ LOT ~ ~~ SECTION_~T ~/~ N-R ~l W, Town of ~~co~,•, ST. CROIX COUNTY, WISCONSIN PLAN VIER SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM ~ ~~~~ ~~5~r`-~~ferNa~'e ~~ ~~_ ~ TZ. Sd.J T3 ~ ~~ I~ INDICATE NOR H Provide setback and elevation information on reverse of this form. ay ~•, 1 1 y~ ~ '' ~', 3~ ,~_ _~_---_____ - ~ - - - a i ~- - - -~- ~ - - - O _. ---- i~_ - - -- o _---- Z - __ ~- 6----- ~~-- ~ Provide 2 dimensions to center of septic tank manhole cover. yf r, BENCHMARK: ~ r/and/~~ t' ~ c,~: c'e~S~ C.o~ ~ irt~ ~L, i6r~ ALTERNATE BM • ,t~o ~,~6,+, . /~ ~ ~,,~ ~- fc r u ~ ~a~~ ~ L tam SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: /„Jie.sav ~. ~ Liquid Capacity: Setback from: Well~_ House /Z~~ Other Pump: Manufacturer /r/~l Model# Float seperation Alarm Location Gallons/cycle: SOIL ABSORPTION SYSTEM Size Width: S-~ Length ~ S ~ Number of trenches 3 Distance & Direction to nearest prop. line:__ rec~,~ a~ ' Setback from: well: B~~ House 3p Other ELEVATIONS Building Sewer ST Inlet: PC inlet Header/Manifold Existing Grade PC bottom ST outlet Pump Off Bottom of system, Final grade DATE OF INSTALLATION : ~ - ! ~ - ~ << PLUMBER ON JOB: 7~C~~,. ~~-, ,.,__ LICENSE NUMBER: /Y/P~Z.s' ~~z5/ INSPECTOR: I~65 3/93 : j t r Wisconsin~Departmentoflndustry, ti Labor and Human Relations Safety and Buildings Division GENERAL INFORMATION PRIVATE SEWAGE SYSTEM INSPECTION REPORT (ATTACH TO PERMIT) Pe,F(p,it.ki~ItiPj~~La; eSTEVEN i{t ^ City ^ village ~ Town of: CST BM Elev.: ~ ~dU ~ U~ Insp. BM Elev.: ~ ~~~ - mil) BM Description: ~~~~ ~ C ~ ~^- TANK INFORMATION TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. vent to Air Intake ROAD Septic ~ ~ ~(p~ ~~I ~ NA Dosi n NA Aeration Holdi PUMP/SIPHON INFORMATION Manuf turer Demand Model Number GPM TDH Lift Fric ~ Syste H Forcemai ength Dia. H Dist. To well S L ABSORPTION SYSTEM ELEVATION DATA -' ST. CROIX Sanitary Permit No.: an iu No.: Q/i,~/9~ STATION BS HI FS ELEV. mark Be nc h O/Srr ~D~,C~ ~ ~ / ~ Idg. Sewer St / Inlet ~/ ~~ 9l0_ ~ St/~ Outlet ~r~ r~ ~~ ~~' Dt Inlet Dt Bottom Header Dist. Pipe ~ :~ Bot. System a ~~ Final Grade ~ 5 ~Sf: C' P / a„ a ~,~„ g a, BED /TRENCH Width r Length / No. Of enches ~ PIT No. Of Pits Inside Dia. Liquid Depth DIMEN 1 N ~~ DIMEN I N SYSTEM TO P/ L BLDG WELL LAKE /STREAM LEACHING Manufacturer: SETBACK INFORMATION Type O ,~~,~,,,, C~lrrh / i / CHAMBER Model Number: System:~e~cs ~ ~ ~ OR UNIT DISTRIBUTION SYSTEM Header / ~MMa22ni ~ Id ~/ ~ ~ Distribution Pipe(s) ~ rr ~ ~ x Hole Size x Hole Spacing Vent To Air Intake Lengthv c~ Dia. Spacing L Length ia3 Dia. TYPE MANUFACTURER CAPACITY Septic ~~~ ~ SGS Dosing r Aeration Ho SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Syst~ Depth Over ,~ Depth Over ~, N xx Depth Of x ded /Sodded xx Trench Center / -3 7 ~ By>~1'rrench Edges 3~- ~ ~ Topsoil ^ Yes ^ No ^ Yes ^ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: HUdson.17.29.19W, SW, SW, Lot 98, R3.dge Pass , _/J~- f~~ Plan revision required? ^ Yes L~7'No Use other side for additional information. SBD-6710 (R 05/91) g ~~ d--- Date Inspector's ignature Cert. No- ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: 1, <~ U`-~j1 ~ (~ ~~. ~~ ,~~, ~ ~ ~~/sir ______-- ~~ ,~ 7 ~ ~'fc~ A •, ~~ ~, jo'~~~„ ~~ ~l U ~ ~ I 'q-~d 4 /o~~ ~~ '~% _ ~ U ~, /~ _5 CA1111TeRV D~RIIAIT ODDI 1[_OTIAN ~3' o1LFIR In accord with ILHR 83.05, Wis. Adm. Code couN STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than 11 I h 8' ~ ^ ~ aqp/ nc es In SIZe. X r C eck if revision to previous application wee r@VerSe Slde fOr If1StrUCtIOrIS fOr COmpl@ting thlS applicatlOn. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION -PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION ~ '/a g~ '/a, S 1 T 'Z , N, R / ~ ~ (or~ PROPERTY OWNE 'S MAILING ADDRESS LOT # BLOCK # ~,~ N CITY, STATE ZIP CODE PHONE NUMB~ SUBDIVISION NAME OR CSM NU BER ~ ~~//~~ 1 ` NEAREST ROAD ~ II. TYPE OF BUILDING: (Check one) ^ State Owned ^ VILTML.AGE ~ ~ Q ^ Public ~1 or 2 Fam. Dwellings of bedrooms ~ PA AX NU BER III. BUILDING USE: (If building type is public, check all that apply) ~ Zd ^ 1 ~,..~ ~ r bG 1 ^ Apt/Condo 2 ^ Assembly Hall 6 ^ Medical Facility/Nursing Home 10 ^ Outdoor Recreational Facility 3 ^ Campground 7 ^ Merchandise: Sales/Repairs 11 ^ Restaurant/Bar/Dining 4 ^ Church/School 8 ^ Mobile Home Park 12 ^ Service Station/Car Wash 5 ^ Hotel/Motel 9 ^ Office/Factory 13 ^ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. ~ New 2. ^ Replacement 3. ^ Replacement of 4. ^ Reconnection of 5. ^ Repair of an System System Tank Only Existing System Existing System B) ^ A Sanitary Permit was previously issued. Permit # - Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ^ Seepage Bed 21 ^ Mound 30 ^ Specify Type 41 ^ Holding Tank 12~ Seepage Trench 22 ^ In-Ground 42 ^ Pit Privy 13 ^ Seepage Pit Pressure 43 ^ Vault Privy 14 ^ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTE~ ELEV. 7. FINAL GRADE ELEVATION h Mi /i q t n. nc ) 1 • REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) ( z 4a~ ~ ~7 `I ~3 ' 9 7$ . ~ 3 Feet Feet ~ ~ S f~ VII. TANK CAPACITY in allons Total #of ' N f t M Prefab. Site Con- Steel Fiber- plastic Exper. INFORMATION New istin Gallons Tanks urer ame anu ac s oncrete strutted glass App. Tanks Tanks Se tic Tank or Holdin Tank Lift Pum Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumber's Signature: (No mps) MP/MPRSW No.: Business Phone Number: ~~,,~ ~ ZZ ~ ! 77 2 321 Plumber's dress (Street, City, State, Zip Code): g' ~ ~ 2 IX. C NTY/DEPARTMENT USE ONLY ^ Disapproved San' ry Permit Fee (includes Groundwater Surcharge Fee) a e ssu Issuing Ag t Si Approved ^ Owner Given Initial Adverse Det rmin lion • X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: l SBD-6398 (formerly PIb~7) (R. 11/86) DISTRIBUTION: Original to County, One Copy To: Safety 8 Buildings Division, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be submitted to the county prior to installation. 5. Onsite sewage systems must be property maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety & Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested in #1-7. VII. Tank information. Fill in the capacity of every new and/or existing tank, list the total gallons, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for a!/ septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. Vttl. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/Department Use Only. X. County/Department Use Only. Complete plans and specifications not smaller than 8'rz x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater, ground- water contamination investigations and establishment of standards. SBD-6398 (R.11/88) r •~ TIMM EXCAVATING Route 1 Box 192 WfLSON, WISCONSIN 54027 (715) 772-3214 (715) 386-5443 MPRS #3224 WI MPCA #696 MN JOB SJ`~ Ueh /`' /.0~~ SHEET NO. -/ OF CALCULATED BY~~ / ' ` ~~' ^"'" DATE 's~ Ze7 ~~ CHECKED BY DATE SCALE PRODUCT 2051®Inc., Groton, Mass. 01471. To Order PHONE TOLL FREE 1-000-2256380 '~' TIMM EXCAVATING Route 1 Box 192 WILSON, WISCONSIN 54027 (715) 772-3214 (715) 386-5443 MPRS #3224 Wt MPCA #696 MN JOB ~""~/1/! ~/L° r~LGI~ SHEET N0. ~- OF CALCULATED BY ~~"'~-^~ DATE ~' Z"oA~ CHECKED BY DATE ecu e - ~~~ d lVl~(jYV PRODUCT 205-1 !~ Inc.,Groton,Mass.01471. To Or0er PNONE TOLL FAEE I-500-225~63~ f DEPARTMENT OF d~N D USrtR Y, LABOR AND HUMAN RELATIONS' REPORT ON SOIL BORINGS AN_ D PERCOLATION TESTS (115) (ILHR 83.0911) & Chapter 145) SAFETY & BUILDINGS DIVISION P.O. BOX 7969 MADISON, WI 53707 LOCATION: ~.:f.~~~~ ~~ SECTION:~~p n,~ l~ ~1` ~ N~N~ E (orlW TOWNSHIP/ ~~41~f L NO.: BLK.NO.: SUBDIVISION AME: ~a(.~.0~-.~ ~~C-l{ COUNTY: c~eO ~ s OWNER'S BUYER'S NAME: M ILING ADDRESS: ~h fl~~~ w) . - ~ ~ ~ T ~ ~~Y ~ T Residence ~~~ ~ ~~ ~ RATING: S= Site suitable for system U=Site unsuitable for DATES OBSERVATIONS MADE PROFI DE R P IONS: PER LAT ON TESTS: New ^Replace I S~~O~f 4 ~~~~~I A ~' ~)l.S 15X' C~CJ~CK~~~~ 1 `( CO NV~ I~Ln~/J~ ENTIO^NAL: SS UU MOUND: ~ Ur(apJrS ~ IN-G~ ND-P-P~ URE: SS U S~EM-IN^-FILL S U HO^LDING~K: S RECOMMENDED SYSTEM:(optional) ~O*~0/l:~I~"'~AL' j~~r~1CU~S If Percolation Tests are NOT re wired DESIGN RATE: 4 If any portion of the tested area is in the under s. ILHR 83.0915)Ib), indicate: CL~~'S I Floodplain, indicate Floodplain elevation: ~t,~ PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUN DWATER-INCHES CHARACTER OF SOIL WITH THICKNESS COLOR TEXTURE AND DEPTH NUMBER DEPTH IN, L EVATION E OBSERVED EST. HIGHEST , , , TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- ~ ~ C~ [ ~ 73,E t~NZ~' } 9.[~ t~ /!~~$l.Sc~iS /~'~ ~.~S4Ge ~S~Cr I$KN ~'-S Tcob B- ~ ~,Z~ g ~~ ®r.)~" > 9,Z~ >r"~.L.is ~~-~$~N L, 4~,~7'ig~vlh5 B- Id.33 /~d.7~ o ~ ~~ > /U-33 /S. &~Ts i7' $r2N StCI e ~Z~L-~ $~eN[- Ms 1F~+ IQ T`~a~ B- ~ >>33 9~,s'z Nd~~ x/1.33 ~~~'g~sZTS 3b'$~NS,~. ~d''~,-~e~~,~1s~~"B~eNcs~-~e B- ~ 10.E 97.rp /e/©N~ > /bTs3 q'`Bec.7s~a"B~e~JI ~3~8e,~~s~~e "'4~,$~n7~ B- ~ lp,l7 ~ ,41 N® >/d,.~7 4~ LtZ-s 3j ~[.i g~Pir S%[. 1~'B S ~~~ ,$fe.~ /I'I~ ~~j PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER IfiC'FfiES AFTER S WELLING INTERVAL-MIN. PERIODI PERIOD2 P R PER INCH P- P- P- A 1 i~_ ~ . f ...._ f ~ ...................G.. .. m ~Ry ~ ~- _~' __ m i 3 ^ _i.v...__._ 'l_~ n~ t_,w ~`: =~,I~TlQN~ : ~' {~IVI~'LET' ::`C3RPt~! ~ - 5~3 - Fa~_ Tu tae ~ res€- _ < . ; accurate Yo€.~? F ~~€~~ ~ ~~ ~ i€€r;l;.~c~le~ 1. Crampl_._ der~~:;-',anon, 2. The usesr:~ inr? n~€€st clea€-1y €~~cilca~te tiwhe~the€~ ihi~~ r:~sider€ce a€~ ~od?1tTlf;l~t;ial l~arc>}es;t: 3. ,€itiAX(~lJ('Ji €,~.~tnkt ~ c~l~ beelrcacart3s ~' c€ar,tet'r:ial it€r~e.~il; 4. is dais a r~r,~~~ c:l re~ " ~ ~a~e€~t Sys`., ~. Cc~rrtplet:e the :>uit-.. '!;y rai:ir~g be ~ `~, SlT= _ _ `~TASL F~ A ~ ~LLl1 TAI~iK C7L1° IF ALL QTEF~ SYSTE~;~ i ~ ~d F1L)LEC - E>AS`s :~' ~. "'€;~fL. t)~!L l . S; ~S. PLEASE us~~ the a}atarevia` ~€€~, ~: ~ ~€~€ i~a€" ,~~~ pa'c~'~ilc ciesrril ic>€~s artci ccampleting'[he plta~[ plan; 7. i'~IAICE A LEI~LI~ r.. = ,ly lo€~aYi€€r~ yvur test lucat:ic~r€s, L?aL~irtg to seal€r is {areierrcd. A sap~arate st~~xet may b~: t€se a €ec, ~ , ~3, T~:~ae sure y€:~ur be+aclar,.arie ,,,'` v l l~svati€:~r~ rr=~erer~t;e ~aoinl ere clearly shav~un, a€~€cl are pet~rnaraer~~t; 9. C€~€~~slete all apprr>~ariate lacy€~s ss, icy dates, r~arrses, addressees ~=~louc~ ~lairi data, ~sercoletio€~ test exe€aaga- tiori, i~f ~€ppr€apriate; ll~, l~ tta€> inf«rra~atio~a ~s~~€:h as flue€.3 alai I, e" ~' €i ~~es rtpt apply, :~, .~ ~tlae ~€pla€~o~>+'iate box; 11. Sign tlae ~turrr~ atad lal<fce yn€ar current a_' l€ <l ytaur cert:ificat_ _ 17. ltllake lec+it~le. c€~lai~as ar~d distril>ut€= I. 11LL SOIL. TESTS t~Sl" E FILEC~ `UNITE-l TIE LL~A~.. r`~t.~~"l-~I~FIITY ~'U'1Tl-Il(~ 3t7 C ~ ~E C l~d'L~:TIZ~. t~RBRE'4~'4ATiC~3 3E RT1E~ t~9 T'ER ;~ csi! SeLsarat€xs and T~.xt€ares S1: ~-Jtf)i~tfE {QVer ~~~} LtC3~ --- ~€aE3bie {,~ - ~~~'~ xe me=d s r. clirlr€? S2std r ; _ `sY -~ "i ...... 7? ' 'JI .._ ~~i .._.. ( _ ,. scl -- ,• L;,;;rr; SVC~ ~ ~..~. L<.;,=irri SEr - Salaf~}~` ~it€'r` sic; - lt:y flay t S R~ _..... ^ ( l . i$6~~ Yt'~ ..... t ' } P 3~ €~'.6h! t P~t'E - i€.ICti TO Tt~E OWNER: CI ~bcals '~~ -- ~f',f1Yt7C~C S5 - Sa~tiS~or~e L.5 --- Lirra€stcar~~.~ l _... s-~ h - ~; ; by -'~'r~r -~ ~ ~ i';m?'P. __ i t3€~ - /} p~ ...... ~~ :4 rru~ t Utz --- L:O(Ttt~i~r?, ctaa€"se trtrx~ _ ~~aray, mer~.~€r?t C~ - f~iStir3~;1: (~ _ ~>rorr~€r~erat. 51ir1~G~ .?W.`;i l~ -- Fri€P1C11 ll1Ma1"la ~I(~~ ~-- ~Cr~Yitil~ F-~EZ~ct'€?tlCB Pr>nt S T C - 105 SEPTIC TANK MAINTENANCE AGREEMENT ~St. Croix County WNER/BUYER `~~~ ~" ~~f~/`c-r ~~' ~/ ADDRESS ~ FIRE NUMBER_ '` t~~/ CITY/STATE 1S~Gr~~"' LU,? ZIP_ ~~/~ Z 7 PROPERTY LOCATIONS ~ 1/4,~kJ 1/4, SECTION « , T~N-R /~ W TOWN OF ~ , 3t. Croix County, SUBDIVISION Lc1~ ~~~ ~'o.~_, LOT NUMBER,~_ Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by a licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County residents may be eligible to receive a grant for a maximum of 60~ of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their system properly maintained. The property owner agrees to submit to St. Croix Zoning a certification 'form, signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1). the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary) , the septic tank is less than 1/3 full of sludge and scum. I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR. Certification stating that your septic has been maintained must be completed and returned to the St. Croix Co. Zoning Offfcer within 30 days of the three year expiration ate. __ ' SIGNED: ~/ n DATE : - 7 '" 2 `~ - ~ t{ St. Croix co. Zoning Office 911 4th St. Hudson, WI 54016 ' STC-100 •This application form is to be completed in dull and signed by the owner(s) of tl~e property being developed. Any inadequacies will only result in delays of the permit issuance. ,Should this development be intended for resale by owner/contractor,(spec douse), then~a second form should~be retained and completed when the property is sold and submitted to this office with the appropriate deed 'recording. Owner of property .Location of•property~i/4 ~~1/4, Section =, T~N-R,~W Township Mailing address Address of site ,~.~~•,..~o subdivision name _ __ l.~~Gl~o~ .. ~ S' • ,~,~ Lot no._ • ~g other homes on property? ves~_No PrQVious owner of property _ I`~CCu...Q T Total size of parcel • Dats parcel•was oreated 'Are all corners and lot lines identifiable? ,~_YeS __No ! . Is this property being developed for (spec house)?,_Yes ~No Volume /d77 and. Page Number =`~~ as recorded with the Register of Deed. ' INCLUDE WITIi THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMDER, VOLUME AND PAGE NUMF3ER & TILE SEAL OF THE REGISTER OF DEEDS. ,In addition, a certified survey, if available, would be helpful~so as to avoid delays of the reviewing process. If the deed description references to a certified Survey Map, the Certsified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I(we) certify that all statements on this form are true to the best of my (our) knowledge that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded the office of the County Register of Deeds as Document No. , and that I (we) presently own the proposed site for the sewage disposal system or I (we) obtained an easement, to run the above described property, for the construction of said system, and the same has been duly recorded in the office of County Rectieta,r ~~ aee.a.. __ ..__.____~ ~~o. N 81 '~' ! i M ~ . . ~ _, ~-~. .,.. P --___ ~ ~. M ~ y ~ ~. wr l0 ERs Nt@S°3'00"N-l .... ,' ' ~ "'" ~ ' ~R'at Sas°16`O~w~ . ' ,~ i-` 'dSO.lS' DRAfNAEE y,llTiklTY AND .1rAt.lEr~Y 3ZdA0~ ~~,: ~~ ~UTL~,O T ;~ - EASEMENT. ,LOW- RID6E_'2n;~,_gp01T10N - .. ~ ,•~ ,_ .. _ .- . ,4 r' ~ ~ ~.~";- . S 89°09~2T_W _ ~ ~ 266Z..33~ :' 1 I ~~ 1 ' ~ ' DO 4 CUMENT No. , WARRANTY DEED THIS SPACE RESERVED FOR RECORDING DATA ' ~ -STATE BAR OF WISCONSIN FORM 2 -1982 ~ 516338 ,,.... VOL - (PAGE 242 __ PalJ1..F..-..T_u.ckne-r-..~n.d...J-a_c_q.u-e.l.ine...S.~---Tu-c.k-ner.,-. hp_sband-.a-n-d. ~,y, ~_ , ..` ,:l~.r y~) ... - ---- ------- ----------- ---- -------------------.. ;, MA 2, 5 199 P: conveys and warrants to .$tPVPn M_.-.F.1.e-tchP.r._3n_d-D-i_3CLe.L~~__: `'' - F.letcher.,.husband and.w.i.fe_, - ....__ ----- ~ ~:~ ~ 1~1 i ,; ......... .. .. ... ..... .. _. .. - .__.. ..-. --_ -. .. __.-...-. -..___ ~:~ RETURN l'O in_considerat.ion .of. --~$26,-00.0-,-0.0 . . .. ................. . --..._. the following described real estate in _..__...-~t•---Cr01-X---- ------_------ County, -: __ State of Wisconsin: Tax Parcel No: Q2Q-1174-6~__ Lot 98, Plat of Willow Ridge East in the Town of Hudson. Subject to a Declaration of Restrictions, Covenants, Conditions recorded in Vol. 541, Page 522 and Vol. 533, Page 468. ,.!:' E~h . .~~~_ This ._ .._.).S `' _ N_~ _. homestead property. (is not) Exception to warranties Dated this __ 5th . day of - ------ - - -May - - -_._.... _._ -. - _, ~s.-94 .. _ . C.J~I~-~C. - .. . --.-- (SEAL) _... (SEAL) -.._. * .-Pau-1-.F-...T.u-ckn-er... __ - -._ ( ~ ~ f (SEAL) -`~CC,µ-J<<~.h.`s.....~~-...'l~l-~~A-4/~ . (SEAL) *_-Jac-queline S, Tuckner __.. AUTHENTICATION Signature(s) ----------------------------------------•------------------ authenticated this -_._-___day of______________________.__, 19___.__ --------------------------- ~. TTT7 L'• T,t r.~wrr~r~r _____________________ ACSNOWLEDGMENT STATE OF WISCONSIN ~ ss. --$t.---CY'O-lX_________________County. Personally came before me t is _-.__5th_--_-day of ---------------- Md v •---------------- , 19 9~ --- the above named - -------- - Paul F. -Tuckner -and---------------------------------------